Department of Health and Social Care (DHSC) – Written evidence (FFF0055)
House of Lords Public Services Committee - Designing a public services workforce fit for the future: call for evidence
Overview
1. The Department of Health and Social Care (DHSC) works through its arm’s length bodies and sector delivery partners on the delivery and implementation of workforce policy.
2. In conjunction with the Department, NHS England and Improvement (NHSEI) is responsible for setting the priorities and direction of the NHS workforce and encouraging and informing the national debate to improve healthcare. Education and training of the regulated health workforce in health and social care is the core function of Health Education England (HEE) which, subject to parliamentary passage of the requisite powers within the Health and Care Bill, will be integrated into NHSEI.
3. The Department has recently commissioned NHSEI to develop a workforce strategy and will set out the key conclusions of that work in due course.
4. NHSEI and HEE have responsibility for shorter term health workforce planning and the deployment of the health workforce to meet service need. Subject to parliamentary assent, the new statutory Integrated Care Board (ICB) proposed in the Health and Care Bill will have a role in aligning and coordinating the planning workforce requirements for its local system. We touch on these responsibilities later in our evidence.
5. The Adult Social Care (ASC) sector is primarily a private and independent sector with over 18,000 separate employers. Our vision is for an adult social care workforce where people can experience a rewarding career, where they are recognised for the vital work they do and feel their wellbeing is prioritised, with opportunities to develop and progress now and in the future.
6. Our White Paper, People at the Heart of Care sets out our adult social care workforce strategy, and is backed up by at least £500 million to help us achieve our vision by developing and supporting the ASC workforce over the next three years. We have also made available two rounds of the Workforce Recruitment and Retention fund, totalling £462.5 million, to support local authorities and care providers recruit and retain care staff through this winter.
7. The Health and Social Care Leadership Review, announced in October 2021, continues to make great progress in considering the best ways to strengthen leadership and management across health and with its key interfaces with social care in England. The review is led by former Vice Chief of the Defence Staff General Sir Gordon Messenger and will report back to the Secretary of State for Health and Social Care in early 2022.
Training and Growing the Workforce
Health
8. This year we have seen record numbers of staff working in the NHS. The monthly workforce statistics for December 2021 show over 1.2 million Full-Time Equivalent (FTE) staff (which is over 1.3 million in headcount) working in the NHS. Since December 2020, there are now almost 20,600 (3.3%) more professionally qualified clinical staff working in NHS trusts and CCGs, including over 4,300 (3.5%) more doctors and over 11,700 (3.9%) more nurses. In total there are over 41,700 (3.6%) more Hospital and Community Health Service staff compared to December 2020.
9. We continue to introduce measures to expand the workforce, with an additional 1,500 Government funded undergraduate medical school places each year for domestic students in England - a 25% increase over three years. This expansion was completed in September 2020 and delivered five new medical schools in England. In addition, the Government lifted the cap on medical and dental school places for students who completed A-levels in 2020 and 2021 and who had an offer from a university in England to study medicine or dentistry, subject to their grades, leading to record numbers of medical students.
10. The Government has committed to deliver 50,000 more nurses by the end of this Parliament. This will be achieved through a combination of investing in and diversifying the training pipeline, recruiting, and retaining more nurses in the NHS. There are already nurses working in the NHS as the result of the work of the nurse 50k programme. On 7th March, DHSC published a progress report, setting out that there are 27,000 more nurses working in the NHS than there were at the start of the Programme. As such, we are on track to meet the target.
11. To support both the 50k Programme and recruitment in general, since September 2020 Government have offered non-repayable grants of at least £5,000 per academic year to eligible students studying pre-registration programmes across nursing, midwifery, and allied health professions. A further £3,000 per year is available to students with child dependents and students studying specialist subjects.
12. Over 30,000 nurses and midwives accepted places to study nursing and midwifery at English universities in the 2021 recruitment cycle. This is a 28% increase compared to the 2019 application cycle. There are currently over 72,000 people training to be nurses, around 9,000 people training to be midwives and over 30,000 training to become Allied Health Professionals.
13. The Government remains committed to growing the GP workforce and number of doctors in general practice and is determined to deliver this as soon as possible. There were 1,672 more Full Time Equivalent doctors in general practice in December 2021 compared to December 2019.
14. DHSC is working with NHSEI, HEE and the profession to increase the general practice workforce in England. This includes measures to boost recruitment, address the reasons why doctors leave the profession, and encourage them to return to practice. The 2020 updated GP Contract Framework announced a number of new retention schemes alongside continued support for existing schemes for the general practice workforce. To boost recruitment, we have increased the number of GP training places. In 2021/22, the highest ever number of doctors accepted a place on GP training - a record 4,000 trainees, up from 2,671 in 2014. In addition to Doctors, the additional roles reimbursement scheme enables Primary Care Networks recruit a wider range of professionals, with over 12,000 recruited as of December 2021. These new staff will provide capacity and a wider range of skills to General Practice, whilst also enabling multi-disciplinary team working in Primary Care.
15. Acknowledging the need for the health workforce to be able to treat a wide range of conditions and support a population with increasing multimorbidity, the Government has included ‘enhancing generalism’ as an ongoing focus. This reform is designed to equip doctors with the skills that the future NHS needs, and which have been much in demand during the COVID-19 response so far. Among these skills, enhanced generalism for doctors is key to addressing health inequalities by creating locally nurtured doctors serving complex population health needs.
16. Alongside enhancing generalism, to further support doctors’ work with multi-morbidities, there is a focus on building multi-disciplinary teams. New roles are being created to support these teams and address shortages in specialties such as anaesthetics and general practice.
17. These roles are Physician Associate (PA), Anaesthesia Associate (AA), Surgical care Practitioner (SCP), and Advanced Critical Care Practitioner (ACCP). These roles will support primary care (in the case of PA) and secondary care.
18. Further growth of the PA position is a key part of the Government's policy to develop a more effective and strong General Practice workforce to meet future patient need. Since 2014, the PA workforce has grown considerably. At present, there are 36 institutions across the UK running courses leading to the award of a PA qualification, with additional providers working to open a PA programme in 2022. As of October 2021, there are 2,486 qualified PAs and 1,000 student PAs on the Managed Voluntary Register (MVR).
19. We are also supporting and investing in alternative routes into healthcare careers. Apprenticeships provide routes into a variety of healthcare careers and are an excellent opportunity to earn, gain work experience and achieve nationally recognised qualifications at the same time.
20. HEE has already taken steps to modernise and widen access to nursing, midwifery and AHP programmes. They have expanded the use of simulated learning and blended learning. HEE anticipate around 8,500 nurses will start training in blended learning programmes over the next 5 years. Nursing Degree Apprenticeships were developed to improve social mobility and widen participation. The Nursing Associate (NA) role was also created to help bridge the gap between Healthcare Assistants and Registered Nurses in England. NAs can take a two-year apprenticeship conversion course to potentially qualify as a registered nurse.
Adult Social Care
21. Employers are struggling to recruit and retain the right number of staff and there are high rates of staff turnover (34% for care workers and 21% for registered managers). Challenges in the sector include the absence of opportunities to train, progress and be rewarded for doing so, as well as burnout and lack of health and wellbeing support from providers and authorities. These challenges are long-term but have been exacerbated by the COVID-19 pandemic.
22. We are continuing to commission and fund a range of training opportunities and programmes to help recruit people into the sector and develop career pathways. These include the Workforce Development Fund (WDF) which distributes around £12 million a year (2020/21) through which employers can bid for funding to pay for their staff to gain training and qualifications at all levels. DHSC also funds the £27 million Think Ahead two year fast-track high-calibre graduate programme to train new mental health social workers.
23. The White Paper People at the Heart of Care includes our longer-term strategy for the social care workforce. Backed up by an investment of £500m, it sets out three key aims to build:
24. These reforms are the first steps on the journey towards our vision for adult social care. Our programmes include a Knowledge and Skills Framework, careers pathways and linked investment in learning and development and will ensure staff feel recognised, rewarded, equipped with the rights skills and knowledge and have their health and wellbeing supported. This investment will enable a five-fold increase in public spending on the skills and training of our direct care workers and registered managers.
25. Alongside this, we will develop a new care workforce hub as a central digital platform for the workforce that will allow staff to easily identify themselves as working in care and signpost the new support available for the workforce. We will also develop new policies to identify and support best recruitment practices locally.
26. We also believe offering funded learning and development opportunities whilst creating pathways for progression will make ASC a more attractive place to work. Workers who receive structured learning and development opportunities feel valued and supported, and are therefore are more likely to remain in their posts (State of Adult Social Care, SfC, 2019).
27. Initial training is essential for ensuring a baseline level of skills and knowledge, which in turn underpins quality of care. That is why the recent white paper set out our plans to invest in a Care Certificate. We will ensure Care Certificate training is high-quality and portable, so that care workers can carry it with them throughout their careers. Longer term, we want it to be a requirement for all care workers to have reached this baseline standard, and we will explore options for how to achieve that.
28. Recognising the pivotal role of Registered Managers in developing a skilled workforce, we want to support this cadre by funding Level 5 diplomas for those without relevant qualifications in addition to creating a bespoke support programme for new registered managers where turnover is particularly high.
29. The White Paper also provides detail on our intention to develop an enhanced assurance framework for adult social care. Our aim is to support improved outcomes and a better experience of care for people and their families. There will be a new duty for the Care Quality Commission to assess local authorities’ delivery of their adult social care duties, including relating to workforce.
International Recruitment
30. The Government has taken steps to make the process of recruiting overseas less costly and more attractive through implementation of the Health and Social Care Visa and an exemption from the Immigration Health Surcharge (IHS) for health and social care staff who come to work in the UK. We have added Care Workers to the Shortage Occupation List. This will make it quicker, cheaper, and easier for social care employers to recruit eligible workers from overseas, helping to fill thousands of vital vacancies.
31. The Government is clear that international recruitment of health and care staff must be managed in accordance with high ethical standards. We published a revised Code of Practice for International Recruitment on 25 February 2021 to guarantee the most stringent ethical standards when recruiting health and social care staff from overseas. The code aligns with the latest advice from the World Health Organisation (WHO) in preventing active recruitment from 47 countries with the most pressing health and social care workforce challenges.
32. It also sets out how the UK can work collaboratively with governments from around the world, forming partnerships to benefit health and social care workers, their country of origin and the UK.
Retention
NHS
33. NHS staff retention rates have improved over the last 5 years. They fell significantly at the start of the pandemic, which we think was at least partly due to COVID-19, as staff delayed leaving/retirement plans to support the efforts against the pandemic.
34. The leaver rate for all staff for the year to September 2021 is 10.5%. This includes people moving to different parts of the health and social care sector as well as people going on maternity leave. This is an increase from 9.6% for the year to September 2020. It is now broadly returning to pre-pandemic levels (10.8% for the year to September 2019).
35. The leaver rate for HCHS doctors (excluding doctors in training) for the year to September 2021 is 6.3%. This is the same as for the year to September 2020. This is slightly lower to pre-pandemic levels (6.7% for the year to September 2019).
36. The leaver rate for nurses and health visitors for the year to September 2021 is 10.0%. This is an increase from 9.0% for the year to September 2020. As with all staff, it is now broadly returning to pre-pandemic levels (10.3% for the year to September 2019).
37. Leaver rates fell during the worst months of the pandemic. The increase we’re now seeing is partly as the worst months of the pandemic are not included in the annual figures.
38. Office for National Statistics (ONS) comparisons of retention rates for nurses and doctors show these are higher than most other areas of the public sector. The public sector as a whole has higher retention rates than private sector occupations.
39. We know that NHS staff have worked tirelessly to provide excellent care throughout the pandemic and looking after the wellbeing of staff is crucial. The NHS People Plan prioritises the wellbeing of the NHS workforce, both as an end in itself and to support workforce retention. It set out a comprehensive range of actions to strengthen health and wellbeing support, promote flexible working and support the development of a more compassionate and inclusive culture in the NHS workplace.
40. Delivery of the People Plan is overseen by NHSEI and they have also established a People Recovery Task Force to ensure there is a framework and a set of interventions which will ensure that all NHS staff – including students and trainees – are kept safe during the pandemic. This includes:
41. The people priorities for 2021/22 and 2022/23 are set out in the NHS national planning guidance. This builds on the framework set out in the NHS People Plan and is informed by learning from the pandemic.
42. Improving retention is a crucial response to the supply challenge we face in supporting elective recovery. The NHS Retention Programme continues its work to understand why staff are leaving, resulting in targeted interventions to support staff to stay whilst keeping them well.
43. The NHS is one of the most diverse organisations in this country and we hugely value the contribution that all staff make to delivering care and supporting patients. However, data shows that disabled staff and staff from an ethnic minority background face greater challenges when it comes to violence and abuse, bullying and harassment, and career progression. If the NHS is to be a model employer and make the NHS the best place to work, it must reflect the communities it serves. NHS leaders are accountable for developing and delivering plans to eliminate inequality in their organisations through the Workforce Race Equality Standard and the Workforce Disability Equality Standard.
44. While much is being done, we are not complacent and both the Department and NHSEI will continue to seek to understand what further action will help support staff in keeping well and feeling supported while doing the difficult jobs that they do.
Adult Social Care
45. We know from our own data, and reports from Skills for Care, that common challenges to recruitment and retention include pay and wider terms and conditions outside the care sector, , stress and burnout, distance travelled to work and lack of training and qualification opportunities.
46. In addition to the reforms summarised above and set out in detail in the adult social care White Paper, the Government is implementing a range of interventions which aim to address these challenges.
47. Firstly, we are providing support for local authorities who can work with care providers to determine a fair rate of pay based on local market conditions. Local authorities can make use of over £1 billion of additional resource specifically for social care in 2022/23. This includes the increase in Social Care Grant and the improved Better Care Fund, a 1% ASC precept and deferred flexibilities from last year's settlement.
48. This funding is designed to ensure key pressures in the system are met, including National Living Wage and National Minimum Wage. An increase in the rate of the National Living Wage means many of the lowest paid care workers will have benefited from at least a 2.2% pay rise effective from April 1st.
49. To support the wellbeing of the care workforce, we have worked alongside NHSEI and other organisations to provide a package of emotional, psychological and practical resources, including publishing wellbeing guidance on gov.uk aimed at both workers and their employers. This package includes support helplines, guidance, bereavement resources and a bespoke package of support for registered managers. Additional mental health and wellbeing resources will follow this year, including access to talking therapies, coaching and listening services. We are working with the sector to ensure that wellbeing resources and bestpractice advice are streamlined and easier to navigate. The social care workforce race equality standard will strengthen practice and boost career opportunities for people from minority ethnic backgrounds whilst supporting wellbeing and overall capacity
Planning for the Future
50. The announcement of the Government’s intention to integrate HEE and NHSEI is a major step towards unifying workforce planning across the health system so that we are better able to ensure that we train and recruit the right mix of staff to maximise the return on our investment.
51. This integration will help ensure that service, workforce and finance planning are integrated in one place at a national and local level. It will also simplify the national system for leading the NHS, ensuring a common purpose and strategic direction.
52. Subject to parliamentary approval, it is our intention to formalise the integration of HEE and NHSEI using the transfer of functions powers contained in the Health and Care Bill. Ahead of the exercise of these legal powers, HEE and NHSEI will begin to integrate their structures and work. This two-stage process will help smooth the transition and ensure that we start to the see the benefits of the integrated organisations more quickly.
53. HEE has been commissioned to review long term strategic trends for the health and regulated social care workforce and update the existing long term strategic framework for the health workforce.
54. This will help underpin actions which will ensure the system has the right numbers, skills, values and behaviours to deliver world leading clinical services and continued high standards of patient care. For the first time ever, the framework will also include regulated professionals working in social care, like nurses and occupational therapists.
55. This work will look at the key drivers of workforce demand and supply over the longer term and will set out how they may impact upon the required shape of the future workforce, to help identify the main strategic choices.
56. Building on this work, the Department has commissioned NHSEI to develop a long term workforce strategy, and will set out the conclusions of this work in due course.
57. Further, the Department commissioned the Care Policy Evaluation Centre (CPEC)1 to produce projections of the long-term demand on ASC services under the current system. These include projections over a 20-year period of:
58. CPEC projections account for trends in the key drivers of demand and costs of providing different care services.
Integrated Care Systems
59. ICSs are partnerships of health and care organisations that come together to plan and deliver joined up services The Health and Care Bill builds upon on the work of existing non-statutory Integrated Care Systems (ICSs) by establishing new NHS bodies known as Integrated Care Boards and requiring the creation of Integrated Care Partnerships in each local system area. These will improve the health of people who live and work in their area, including working to ensure the system is retaining, recruiting and, where required, growing its workforce to meet future need.
60. As we respond to the challenges that the pandemic has placed upon the health and care system, Integrated Care Boards (ICBs) will have a critical role to play in growing, developing, retaining and supporting the entire health and care workforce locally. To support them in fulfilling this role, in August 2021 NHSEI published draft guidance on the ICS People function (Building strong integrated care systems everywhere: guidance on the ICS people function).
61. Once established, and subject to Parliamentary approval, the draft guidance states ICBs will have specific responsibilities for delivering against the themes and actions set out in the NHS People Plan, as well as new people requirements outlined in guidance. These include a role for ICBs in growing the workforce for the future and enabling adequate workforce supply, through strategic planning and collaboration across the system to ensure that current and future population, service, and workforce needs are met. In addition to this, the draft ICS people function guidance further sets out the expectation that ICBs will work with partners within the ICB area to develop system workforce plans for the entire health and care workforce – based on population health needs and taking an integrated planning approach across workforce, finance and activity. The draft guidance also asks ICBs to work with regional and national workforce teams to support aggregated workforce planning and to inform prioritisation of workforce initiatives.
62. In addition to this, the draft guidance also has a focus on the training and development of the current workforce. ICBs will be expected to enable staff to learn and work together, as well as flexibly across different parts of the system, whilst developing a consistent system approach to managing talent, supporting social mobility and the potential for lifelong careers across health and care. ICBs will also have a responsibility in ensuring there is accountability for delivering the health and wellbeing agenda across the local system area, including strengthening staff engagement, experience and wellbeing to build workforce resilience across the system.
63. NHSEI will, including through its regional teams, have a role in supporting ICBs to deliver these priorities and responsibilities.
64. Integration requires a workforce equipped with the skills and opportunities to move across the health, public health and social care family, supported by holistic workforce planning to ensure there are the right people to deliver the best outcomes for service users and populations. The Integration White Paper sets out our intention to accelerate workforce integration by removing barriers to collaborative planning and working.
65. Integration will happen at a local level – central government’s role is in facilitating and supporting that, ensuring the right structures, accountability and leadership are in place to enable workforce integration locally.
18 March 2022